Care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year.
In 2012, the San Francisco General Hospital (SFGH) Care Transitions Taskforce was chartered to create a comprehensive program to improve care for recently discharged patients. Using a coordinated approach that includes inpatient and outpatient stakeholders across the continuum of care, the Taskforce supports evidence-based interventions, disseminates actionable data dashboards and successful innovations throughout the San Francisco Health Network (SFHN), and partners with other local initiatives.
The Care Transitions Taskforce is a multidisciplinary group consisting of physician and nursing leaders and front-line providers, pharmacists, nurses, social workers, medical assistants, administrators, and a healthcare analyst that works collaboratively to design, implement, and evaluate care transitions improvements. The Taskforce is subdivided into four teams focusing on inpatient, outpatient, “high risk patients”, and pharmacy interventions. Each team has a lead committed to its process and deliverables. The Taskforce meets twice a month and the subgroups meet additionally, as needed.
The inpatient group is comprised primarily of clinicians and has partnered with the hospital’s Information Systems department to create improvements in discharge documentation and patient education. This group has also developed a modified version of Project BOOST’s 8P’s tool to help identify patients at high risk for post-discharge adverse events and a “playbook” to guide clinicians and staff on appropriate resources and interventions.
The outpatient group, or Post-Discharge Standards Workgroup, meets monthly to discuss post-discharge improvement work including timely access to follow-up, standardized visits, and telephone outreach for high-risk patients. Members of this group, primarily outpatient physicians and nursing managers, design, implement, and evaluate innovative approaches to improving care transitions in a resource-limited system.
Since its inception in 2012, the Taskforce has improved communication between providers, streamlined access to information, and accelerated expansion of pilot projects. The group continues to develop and implement innovative, collaborative strategies for improving the quality of care transitions in San Francisco.
For more information, please contact Dr. Michelle Schneidermann.